Cancer’s Ordered Disorder

By Abigail Zuger, M.D.

Aug. 26, 2013

We have no shortage of dispatches from the cancer wars, what with doctors, patients, essayists, scientists and journalists in every possible combination and permutation all checking in at length from the front.

Dr. Siddhartha Mukherjee’s authoritative 2010 Pulitzer Prize-winning “biography” of cancer, “The Emperor of All Maladies,” ran almost 600 pages. In comparison, George Johnson has written a very small book, barely half that length. That Mr. Johnson’s story is as gripping, illuminating and affecting as the bigger book — or, for that matter, any other book out there — is testament to both his poet’s talents and his unusual perspective.

An award-winning science writer, Mr. Johnson was for some years an editor at The New York Times and a contributor to Science Times (where portions of this book eventually appeared). Initially, though, his interests kept him firmly on the physical science side of things, covering particles and planets, a foreign terrain that often seems enviably organized, if a little dry, to those of us in the mushier, less rigorous zones of health.

Then came a sad new assignment, self-imposed: Mr. Johnson set out to learn everything he could about cancer when his then-wife received a diagnosis at a relatively young age. So he gamely crossed over from the hard sciences to the soft, Gulliver with a notepad and a recorder. He understood the language well enough, but the customs were surpassing strange.

For comfort, perhaps, Mr. Johnson starts his cancer tour where any self-respecting cosmology fan would: not with humans but with dinosaurs. When did it all begin? In 1999, an Ohio rheumatologist with a sideline in fossils identified the oldest presumed example of metastatic cancer in a fragment of 150-million-year-old mineralized dinosaur bone. It turns out that the overall estimated rate of bone cancer in dinosaurs is actually quite similar to that identified in at least one random collection of human bones (not much support there for a theory that cosmic rays killed off the dinosaurs in a cancer epidemic).

But barring that catastrophe, what made that one poor, limping dinosaur so unlucky? Was it too few lycopene-rich fruits? Too much secondhand forest-fire smoke? And how extraordinary, speaking of risk factors, that the rotten luck of our fellow humans still perplexes us almost as much as the luck of that petrified reptile.

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Mr. Johnson’s wife, Nancy, was a trim, exercising, vegetable- and fiber-chomping nonsmoker in her early 40s when she felt a lump in her groin. It proved to be a metastasis from a malevolent form of uterine cancer, one whose cells are atypically aggressive and prone to spreading. Her situation and her terrible prognosis reminded Mr. Johnson of nothing more than his New Mexico backyard, with headstrong wildflowers blooming where they choose and intractable weeds exploding by night.

A man may plan a garden, but nature has different patterns in mind, patterns so intricate and orderly in their chaotic way that scientists now understand cancers to be collections of cells as complex and ambitious as any healthy organ. The extraordinary determination of those cells wins Mr. Johnson’s grudging admiration: “Cancer cells are those that rebel against their fate — they hope for so much more.”

So his story moves between the Santa Fe facilities where Nancy gets her grueling but ultimately successful treatments and the many scientific planes of cancer — from the disregulated events in the cells to the sometimes equally confusing proceedings in hospitals, labs and conference halls, as humans muster their defenses, often feeble but sometimes effective. (Nancy’s treatment led to a prolonged, continuing remission of her disease.)

It turns out that Mr. Johnson’s deceptively casual narrative route is cannily chosen. He wanders everywhere, an intelligent, skeptical, interested and saddened observer with no particular prejudices or axes to grind. He knows how biologic systems work — and, equally important, he is an expert observer of those who observe for a living, and well acquainted with scientific doublespeak. Mr. Johnson finds little in the cancer world to startle him except for the occasional rudeness of some clerical personnel.

“No cancer drug is as good as it sounds”: this observation elicits neither surprise nor outrage. Instead, it seems to him perfectly logical, now that cancer appears to be not a single disease but thousands, each with its distinct molecular signature. He considers research into carcinogens of edible, breathable and radiant forms, and concludes, “Sometimes it feels like we’re chasing our tails, obsessed with finding causes where there may be none.”

“That is the nature of living in a universe dominated by entropy — the natural tendency for order to give way to disorder,” Mr. Johnson elaborates. “That doesn’t mean we can’t reduce the odds, even if only modestly, that we will get cancer before something else kills us. But genetic errors are inevitable and necessary for us to evolve.”

Most books about cancer strive to transcend their particulars. Some aim for a spiritual moral. Some, like Dr. Mukherjee’s, celebrate how far we have come in the struggle against cancer. Others deplore how far we have to go: the recently published “The Truth in Small Doses,” by Clifton Leaf, vehemently decries the ineptitude of our present campaign and calls for a complete reorganization.

But perhaps not since Susan Sontag has anyone put cancer so firmly and eloquently in its place as Mr. Johnson does, casting it as neither metaphor nor enemy, but simply a natural part of the orderly disorder of the natural world.